Care Manager of Health Home Care Management
About The Position
Sun River Health is a Federally Qualified, nonprofit health center providing comprehensive primary, preventive, and behavioral health services, particularly to underserved and vulnerable communities. The Care Manager has day-to-day responsibility for coordinating care-team activities for patients with complex medical and psychosocial needs and facilitating their access to medical and psychosocial services efficiently and effectively. The position is full-time and based at The Hub in the Bronx, New York. The Care Manager collaborates with patients, families, providers, and other care-team members to develop and coordinate individualized care plans, address barriers to care, support medication adherence, and coordinate transitions from inpatient and emergency services. The role also includes arranging screenings and education, helping patients access benefits and housing resources, and completing timely documentation and assessments in the TREAT system. Duties may change based on organizational needs.
Requirements
- High school diploma or GED.
- At least 2 years of work-related experience.
- Ability to perform the essential job functions, with or without reasonable accommodation.
Nice To Haves
- Bachelor’s degree in a health- or human-services-related field.
Responsibilities
- Coordinate day-to-day activities of the care team for patients with complex medical and psychosocial needs.
- Work with the interdisciplinary care team, including primary care, mental health, residential services, and substance abuse providers, to develop and coordinate care plans.
- Coordinate with the Patient Navigator on field activity and support information flow across the care team.
- Provide input to providers, patients, and families on written individualized care plans; review intake assessments and coordinate care plans, self-management goals, and strategies.
- Identify barriers to care with patients and help address them, including following up with patients who have not met treatment goals and adjusting goals when possible.
- Evaluate medication compliance, assess barriers to adherence, and ensure medication reconciliation is current.
- Respond to alerts about inpatient and emergency-room admissions; visit patients during inpatient stays and participate in discharge planning and care transitions.
- Contact patients within one business day after inpatient or emergency-room discharge.
- Help patients keep appointments and arrange metabolic and periodic preventive screenings in accordance with agency policy.
- Facilitate communication between patients and physicians as needed so patients and caregivers are aware of test results.
- Coordinate services between patients and extended care-team providers to support implementation of integrated care plans.
- Review the TREAT workload report regularly to identify patients requiring assessment, outreach, and engagement.
- Provide or arrange self-management and wellness education, peer support, and other support groups in the patient’s or family’s preferred language.
- Organize and participate in case conferences according to patient needs and agency policy.
- Review benefits, entitlements, and housing with patients and families; assist with applications and follow up on service approvals.
- Use TREAT to complete documentation and assessments on time, including scheduling activities.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
